Child's Name *

First Name

Last Name

Parent / Guardian Name *

First Name

Last Name

Parent Phone *

(###)

###

####

Home Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Child's Grade *

Entering 1st Grade

1st

2nd

3rd

4th

5th

6th

Child's Date of Birth *

MM

DD

YYYY

I give permission for photos to be taken of my child(ren) for internal viewing purposes only *

Yes

No

I give permission for emergency medical attention in the event that I am not reachable *

Yes

No

I warrant that my child is fully capable of safely participating in all VBS Activities & release CABC/VBS from all liabilities resulting from these activities *

Yes

No